Key takeaways

  • TIFFA is done once, between 18 and 22 weeks (around 20 weeks is ideal), and is recommended for all pregnancies regardless of age or risk.
  • It systematically checks the brain, face, heart, chest, abdomen, kidneys, spine, limbs, placenta and fluid — a thorough scan takes 30-45 minutes.
  • It detects roughly 70-85% of major structural anomalies at experienced centres, but no scan can rule out every condition.
  • "Soft markers" are minor findings; a single isolated marker in a low-risk pregnancy usually means nothing is wrong.
  • Under the PCPNDT Act, your doctor cannot tell you the baby's sex — and you should not ask.
  • Government tertiary centres offer TIFFA free under JSSK; cost should never be a reason to skip it.

What TIFFA is, and why 18-22 weeks

TIFFA stands for Targeted Imaging For Fetal Anomalies. It is a detailed second-trimester ultrasound that systematically examines your baby's anatomy to look for major structural anomalies — the way the brain, heart, spine, kidneys, limbs and other organs have formed. You may hear it called by several names: the anomaly scan, the 20-week scan, a Level II ultrasound, or a detailed obstetric scan. They all mean the same examination.

The 18-22 week window is chosen carefully. By 18 weeks most major organs are developed enough to see clearly, yet the baby is still small enough to fit in standard ultrasound views and there is plenty of amniotic fluid to give a clear picture. There is also a practical reason specific to India: the MTP Act allows termination up to 24 weeks for substantial fetal abnormality, so a scan completed by 22 weeks leaves time for counselling, any extra testing and unhurried decisions before the legal deadline.

A "Level I" scan is the basic check most women have earlier — dating, placental position, fluid and simple measurements. TIFFA is the comprehensive "Level II" version. Some fetal-medicine units offer an even more detailed "Level III" or targeted scan for high-risk pregnancies or to follow up a concern; these take longer and use more advanced equipment.

Every pregnancy benefits from TIFFA. Because most anomalies occur in women with no risk factors at all, skipping the scan means most would simply go undetected before birth. Detecting a problem early allows you to plan delivery at a centre with the right paediatric specialists, understand treatment options, and make informed choices.

Who needs extra scans beyond standard TIFFA

Standard TIFFA is enough for most pregnancies. Some situations, though, call for referral to a fetal-medicine specialist and additional, more detailed scanning:

What the scan checks, head to toe

TIFFA follows a structured protocol set out by ISUOG (the international ultrasound society) and FOGSI in India, examining the baby system by system. A thorough scan takes 30-45 minutes. Here is what the sonographer is looking at:

Head, brain and face. The skull shape and integrity, the midline brain structures, the size of the fluid spaces (ventricles), the cerebellum at the back of the brain, the profile and eyes, the nasal bone, and the lips (looking for a cleft). The palate is harder to see, so a cleft palate without a cleft lip can occasionally be missed.

Chest and heart. The diaphragm should be intact (a gap can mean a diaphragmatic hernia) and the lungs should look normal. The heart is the most challenging part of any anomaly scan: the sonographer checks the four-chamber view plus the outflow vessels. Because even good scans detect only a portion of heart defects, a dedicated fetal echocardiogram is recommended whenever there is higher risk or any cardiac concern.

Abdomen and kidneys. The stomach (normally on the left), bowel, liver, both kidneys, the bladder, and an intact abdominal wall. The umbilical cord is checked too — it normally has three vessels; a two-vessel cord is found in about 1% of pregnancies and is often an isolated, harmless finding.

Spine and limbs. The spine is followed along its full length to confirm the bones line up and the skin over it is intact (the key check for spina bifida). All four limbs are seen moving, and the thigh bone (femur) is measured as part of standard growth biometry.

Placenta and fluid. The scan records where the placenta sits relative to the cervix — a low-lying placenta may suggest placenta praevia, which usually moves up as the uterus grows but needs a follow-up scan later. It also measures the amniotic fluid, and some centres add a cervical-length check by transvaginal scan if there is a risk of preterm birth.

What TIFFA can detect — and the honest limits

Detection rates vary by the specific anomaly, the equipment and the sonographer's experience. The figures below are broad averages from large studies; tertiary fetal-medicine centres in India approach the higher end, while basic ultrasound rooms may detect less.

Brain and spine anomalies are among the best detected — anencephaly (absent skull and brain) at 95-99%, open spina bifida at 85-95%, and major hydrocephalus at 75-90%. Subtler findings like absence of the corpus callosum (50-80%) are more easily missed.

Heart defects are the hardest. Overall congenital heart disease detection on TIFFA is roughly 40-70%. Large defects like an AVSD (often linked with Down syndrome) are found more reliably, while small holes between the chambers and a narrowing of the aorta are frequently missed. A targeted fetal echo lifts detection of major heart disease to 80-95% and is recommended for diabetes, a family history of heart defects, identical twins or any cardiac concern.

Other anomalies vary: cleft lip 80-90% (palate-only clefts lower), diaphragmatic hernia 60-85%, abdominal-wall defects 90-95%, and bilateral absent kidneys 90-95%.

Down syndrome is an important caveat. TIFFA alone catches only about half of cases, because many babies with Down syndrome have a completely normal anatomy scan. Down syndrome and other chromosomal conditions are screened far better by first-trimester combined screening and by NIPT earlier in pregnancy. The overall detection for major structural anomalies on TIFFA is around 70-85% at good centres — a normal scan is genuinely reassuring, but it is not a guarantee of a perfectly healthy baby in every respect.

Soft markers: what they mean (usually not much)

Soft markers are minor findings that are not anomalies themselves. They are common in completely normal pregnancies, but slightly more common when there is an underlying chromosomal condition. What matters is whether a marker is isolated or appears with other findings, and your overall risk from earlier screening.

Common soft markers include an echogenic intracardiac focus (a tiny bright spot in the heart, seen in 3-5% of normal pregnancies), mild pyelectasis (slight fullness of the kidney's drainage area), a single umbilical artery, a short femur, and choroid plexus cysts in the brain. Most of these, when isolated and in a low-risk pregnancy, carry no real significance.

A few markers carry more weight: an increased nuchal fold (the soft tissue at the back of the neck thicker than 6 mm), echogenic (bright) bowel, an absent or small nasal bone, and persistent mild ventriculomegaly. These prompt a closer look and a discussion about further testing.

Management is about context. A single isolated marker in a low-risk pregnancy is usually handled with reassurance and routine care — no extra tests needed. Multiple markers, or a marker plus an abnormal screen, raise the overall risk and may lead your specialist to discuss NIPT or Amniocentesis in India: When It's Needed, Risks, Results & NIPT. The honest message: do not panic over an isolated soft marker, but do follow through on any recommended check. Genetic counselling can help you weigh the numbers calmly before deciding on anything invasive.

When to see a doctor (or a fetal-medicine specialist)

Most women never need more than the standard scan. Speak to your obstetrician promptly, and accept referral to a fetal-medicine specialist, if any of the following apply:

The combined approach: first-trimester screening, NIPT and TIFFA

No single test finds everything, so modern pregnancy care layers several screens, each playing to its strength. All are available in India at varying cost and access.

First-trimester combined screening (11-13 weeks) blends your age, the nuchal-translucency measurement and two blood markers to estimate the chance of Down syndrome and a few other conditions. It detects about 85-90% of Down syndrome cases. This is also the best moment to confirm chorionicity in twins. Read more in our NT and nasal-bone screening guide.

NIPT (non-invasive prenatal testing) is a maternal blood test from about 10 weeks that analyses the baby's DNA in your blood. It detects over 99% of Down syndrome and high proportions of trisomy 18 and 13. It is a screening test — an abnormal result still needs confirmation by CVS or amniocentesis — but a normal result is very reassuring. Our NIPT cost and accuracy guide covers Indian labs and pricing.

TIFFA at 18-22 weeks then adds what blood tests cannot see: the baby's physical structure. Together, first-trimester screening (or NIPT) plus TIFFA give the most complete antenatal picture. If a confirmatory diagnosis is needed, CVS earlier or amniocentesis later provide it. Counselling before testing — so you know what each result would mean for you — is as important as the tests themselves.

MTP Act 2021: options after a fetal anomaly is found

If TIFFA finds a serious anomaly, you have decisions to make, and Indian law gives you room and time. The Medical Termination of Pregnancy Act, amended in 2021, sets the framework.

Up to 20 weeks, termination needs the opinion of one registered doctor; from 20 to 24 weeks it needs two doctors and applies to defined categories, including fetal malformation. For a substantial fetal abnormality, termination is generally permissible up to 24 weeks. Beyond 24 weeks it requires approval from a State-constituted Medical Board.

What this means in practice depends on the condition. Anomalies incompatible with life (such as anencephaly or bilateral absent kidneys) and severe disabling anomalies are covered up to 24 weeks with counselling and documentation. Milder, treatable anomalies raise more complex medical and ethical questions, and realistic counselling about the baby's likely outcome matters most here.

Whatever the situation, you deserve thorough, unhurried counselling — about the specific anomaly, its prognosis, the treatments available after birth, and what termination would involve — ideally with the relevant paediatric specialists and a geneticist. If the condition is genetic, counselling should also cover the chance of recurrence in a future pregnancy.

This is one of the hardest moments a family can face. Grief is normal and valid whichever way you decide, and mental-health support should be part of your care. Our guide on coping with pregnancy loss may help. MTP is free at government facilities under JSSK.

PCPNDT Act: why your scan will not reveal the baby's sex

The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 governs every prenatal scan in India. It was enacted to stop sex-selective abortion and the skewed sex ratio it produced. It is essential to understand for both patients and providers.

The Act prohibits determining or disclosing the sex of the fetus by any method, including ultrasound — even if the sex is incidentally visible during a legitimate scan. Every scan centre must be registered, and every examination is documented on Form F, signed by you and the doctor, stating the medical reason for the scan and confirming no sex determination was done.

Penalties are serious: imprisonment of up to 3 years and fines for healthcare providers, and up to 3 years and a fine for a patient or family member who seeks sex determination. The medical registration of an offending doctor can be suspended.

What this means for you is simple. Do not ask your obstetrician or sonographer about the baby's sex — they cannot tell you even if it is visible, and asking places them in a difficult legal position. The TIFFA report should never mention sex. Your care team focuses on the medical aspects — anatomy, growth, fluid and placenta. The only exception is a small set of genuinely sex-linked genetic conditions, which require specific approvals and documentation. If any provider offers to reveal the sex, decline — it is illegal for everyone involved.

Costs, access and government schemes in India

Cost varies widely between government and private facilities, and between a basic scan room and a dedicated fetal-medicine unit. A useful rule: cost should never be the reason you skip TIFFA.

Typical private prices are roughly Rs 3,000-6,000 for a standard TIFFA, Rs 5,000-12,000 for an advanced fetal-medicine scan, and Rs 4,000-8,000 for a fetal echo. Genetic counselling runs about Rs 1,000-3,000 a session. NIPT is Rs 12,000-25,000, and diagnostic CVS or amniocentesis with a microarray can reach Rs 15,000-30,000.

Government schemes cover much of this. Under JSSK, government tertiary centres provide TIFFA, fetal echo, genetic counselling and diagnostic testing free. PMSMA offers free monthly specialist antenatal consultations for high-risk pregnancies, and some centres schedule TIFFA on those days. PMJAY (Ayushman Bharat) covers up to Rs 5 lakh of secondary and tertiary care a year at empanelled hospitals, and most states run their own schemes too.

A few practical tips: book TIFFA for around 20 weeks and do not let it slip; choose a centre with proper equipment and a trained sonographer rather than a basic scan room; carry your earlier scan and blood-test reports; and if budget is tight, a government tertiary centre will do a thorough TIFFA free under JSSK even if your other care is private. If a concern is found, accept fetal-medicine referral quickly — delays only shrink your options and time.

TIFFA in twin and multiple pregnancies

Twins add complexity. Each baby needs the full head-to-toe survey, so a twin TIFFA typically takes 60-75 minutes. The two babies are labelled consistently (Twin A and Twin B) to match the labelling from the chorionicity scan at 11-13 weeks.

Twins carry about twice the structural-anomaly rate of singletons, and identical (monochorionic) twins more so — including a markedly higher rate of heart defects. For that reason, a fetal echo is recommended for all monochorionic twins at 20-22 weeks. Monochorionic pairs also need extra surveillance for twin-to-twin transfusion syndrome (TTTS) from around 16 weeks.

If an anomaly is found in one twin, the options depend on the type of placentation and the severity, and decisions are made with a fetal-medicine specialist. Selective procedures are technically possible but more complex in shared-placenta (monochorionic) pregnancies and need specialised centres. Our complete twin pregnancy guide covers this in depth.

The bottom line: a twin anomaly scan is longer and more demanding, so it is best done by an experienced sonographer or a fetal-medicine unit. Plan ahead and book accordingly.

Indian myths about TIFFA, corrected

Myth: TIFFA can detect all birth defects

  • Not true, and worth understanding clearly. TIFFA detects around 70-85% of major structural anomalies at experienced centres, with real gaps for some conditions. It does not reliably find many genetic syndromes without an obvious physical feature, autism, intellectual disability without a structural cause, deafness, small heart defects, or some bowel problems.
  • Layering tests — first-trimester screening, NIPT, TIFFA, a fetal echo for high-risk pregnancies and third-trimester growth scans — gives the most complete picture, but still cannot catch everything. A normal TIFFA is reassuring for what it covers, not a promise of perfect health, which is why the newborn check and developmental follow-up after birth still matter.

Fact: TIFFA should be done at 18-22 weeks for every pregnancy

  • Many Indian women still miss TIFFA because of cost worries, low awareness, or care at a facility without the capability. That is a serious gap: 2-4% of pregnancies carry a major anomaly, and most occur in women with no risk factors at all.
  • Detecting an anomaly early lets you plan delivery where the right specialists are, understand treatment, and make informed choices within the law. Cost should not stop you — government tertiary centres offer free TIFFA under JSSK, PMSMA covers high-risk specialist visits, and PMJAY covers private scans at empanelled hospitals.

Myth: I can ask the OB for the baby's sex during TIFFA

  • Illegal. The PCPNDT Act, 1994 prohibits determining or disclosing fetal sex by any means, including ultrasound, even if it is incidentally visible. Asking puts your doctor in a difficult legal position and can be an offence on your part too. Penalties include up to 3 years' imprisonment and fines.
  • Your care team focuses on anatomy, growth, fluid and placenta, and will not comment on sex even if asked. The report should never mention it. The underlying issue of gender preference is a social one that India addresses through campaigns like Beti Bachao Beti Padhao — but the medical system cannot and will not facilitate sex determination outside very specific genetic indications.

Fact: soft markers usually do not mean something is wrong

  • Soft markers — a bright spot in the heart, mild kidney fullness, a choroid plexus cyst, a single umbilical artery, a short femur — are common in normal pregnancies and only slightly raise the chance of an underlying condition. An isolated marker in a low-risk pregnancy is usually managed with reassurance and routine care.
  • Multiple markers, or a higher-weight marker plus an abnormal screen, do warrant a fetal-medicine review and a discussion about NIPT or diagnostic testing. The right response is neither panic nor dismissal — it is context-specific guidance from your specialist, and following through on whatever is recommended.

Frequently asked questions

Is the TIFFA scan painful or risky for my baby?

No. TIFFA is a standard ultrasound — the same safe sound-wave technology used throughout pregnancy. It is painless, involves no radiation and no injections, and is not known to harm the baby. You may be asked to drink water beforehand or to come with a comfortably full bladder; the sonographer will guide you.

What if my baby is in an awkward position during the scan?

It is common. If the baby is lying in a way that hides certain structures, the sonographer may ask you to walk around, empty your bladder, eat something or lie on your side, then re-scan. Occasionally you will be asked to return another day to complete a few views. This is routine, not a sign that anything is wrong.

Can TIFFA tell me the sex of my baby?

Even if the sex is visible, your doctor and sonographer cannot legally tell you. India's PCPNDT Act prohibits any disclosure of fetal sex, and the report will not mention it. Please do not ask — it places your care team in a difficult legal position and can be an offence on your part.

My scan found a 'soft marker' — should I be worried?

Usually not. A single isolated soft marker in a low-risk pregnancy most often means nothing is wrong and is managed with reassurance. If there are multiple markers, or a marker alongside an abnormal earlier screen, your doctor may suggest a fetal-medicine review or further testing. Ask your specialist to explain your specific situation rather than searching worst cases online.

What happens if TIFFA finds a serious problem?

You will be referred to a fetal-medicine specialist for a detailed re-scan and counselling about the condition, its outlook, treatment after birth, and your choices. Depending on the diagnosis, you may be offered confirmatory testing such as amniocentesis. Under the MTP Act, termination is permissible up to 24 weeks for substantial fetal abnormality. The decision is yours, with full information and support.

Can I have TIFFA done free in India?

Yes. Government tertiary centres and many medical colleges provide TIFFA free under the JSSK scheme, and PMJAY covers it at empanelled private hospitals for eligible families. If your private centre's fee is a barrier, ask to be referred to a government tertiary centre for this one scan — cost should never be the reason to skip it.

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